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Bulut E, Johansen PM, Elbualy A, Kalman C, Mayer R, Kato N, Salmeron de Toledo Aguiar R, Pilitsis JG. How Long Does Deep Brain Stimulation Give Patients Benefit? Neuromodulation 2024:S1094-7159(24)00128-4. [PMID: 39001725 DOI: 10.1016/j.neurom.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/01/2024] [Accepted: 05/22/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION One of the most common questions patients ask when they are contemplating deep brain stimulation (DBS) is how long it will last. To guide physicians in answering this query, we performed a scoping review to assess the current state of the literature and to identify the gaps that need to be addressed. MATERIALS AND METHODS The authors performed a MEDLINE search inclusive of articles from January 1987 (advent of DBS literature) to June 2023 including human and modeling studies written in English. For longevity of therapy data, only studies with a mean follow-up of ≥three years were included. Using the Rayyan platform, two reviewers (JP and RM) performed a title screen. Of the 734 articles, 205 were selected by title screen and 109 from abstract review. Ultimately, a total of 122 articles were reviewed. The research questions we explored were 1) how long can the different components of the DBS system maintain functionality? and 2) how long can DBS remain efficacious in treating Parkinson's disease (PD), essential tremor (ET), dystonia, and other disorders? RESULTS We showed that patients with PD, ET, and dystonia maintain a considerable long-term benefit in motor scores seven to ten years after implant, although the percentage improvement decreases over time. Stimulation off scores in PD and ET show worsening, consistent with disease progression. Battery life varies by the disease treated and the programming settings used. There remains a paucity of literature after ten years, and the impact of new device technology has not been classified to date. CONCLUSION We reviewed existing data on DBS longevity. Overall, outcomes data after ten years of therapy are substantially limited in the current literature. We recommend that physicians who have data for patients with DBS exceeding this duration publish their results.
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Affiliation(s)
- Esin Bulut
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - P Mitchell Johansen
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Alya Elbualy
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Cheyenne Kalman
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Ryan Mayer
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Nicholas Kato
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Julie G Pilitsis
- Department of Neurosurgery, University of Arizona, Tucson, AZ, USA.
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Acevedo N, Rossell S, Castle D, Groves C, Cook M, McNeill P, Olver J, Meyer D, Perera T, Bosanac P. Clinical outcomes of deep brain stimulation for obsessive-compulsive disorder: Insight as a predictor of symptom changes. Psychiatry Clin Neurosci 2024; 78:131-141. [PMID: 37984432 PMCID: PMC10952286 DOI: 10.1111/pcn.13619] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/18/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
AIM Deep brain stimulation (DBS) is a safe and effective treatment option for people with refractory obsessive-compulsive disorder (OCD). Yet our understanding of predictors of response and prognostic factors remains rudimentary, and long-term comprehensive follow-ups are lacking. We aim to investigate the efficacy of DBS therapy for OCD patients, and predictors of clinical response. METHODS Eight OCD participants underwent DBS stimulation of the nucleus accumbens (NAc) in an open-label longitudinal trial, duration of follow-up varied between 9 months and 7 years. Post-operative care involved comprehensive fine tuning of stimulation parameters and adjunct multidisciplinary therapy. RESULTS Six participants achieved clinical response (35% improvement in obsessions and compulsions on the Yale Brown Obsessive Compulsive Scale (YBOCS)) within 6-9 weeks, response was maintained at last follow up. On average, the YBOCS improved by 45% at last follow up. Mixed linear modeling elucidated directionality of symptom changes: insight into symptoms strongly predicted (P = 0.008) changes in symptom severity during DBS therapy, likely driven by initial changes in depression and anxiety. Precise localization of DBS leads demonstrated that responders most often had their leads (and active contacts) placed dorsal compared to non-responders, relative to the Nac. CONCLUSION The clinical efficacy of DBS for OCD is demonstrated, and mediators of changes in symptoms are proposed. The symptom improvements within this cohort should be seen within the context of the adjunct psychological and biopsychosocial care that implemented a shared decision-making approach, with flexible iterative DBS programming. Further research should explore the utility of insight as a clinical correlate of response. The trial was prospectively registered with the ANZCTR (ACTRN12612001142820).
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Affiliation(s)
- Nicola Acevedo
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
- St Vincent's HospitalMelbourneVictoriaAustralia
| | - Susan Rossell
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
- St Vincent's HospitalMelbourneVictoriaAustralia
| | - David Castle
- St Vincent's HospitalMelbourneVictoriaAustralia
- Centre for Addiction and Mental HealthUniversity of TorontoTorontoOntarioCanada
| | | | - Mark Cook
- St Vincent's HospitalMelbourneVictoriaAustralia
| | | | - James Olver
- Department of PsychiatryUniversity of MelbourneMelbourneVictoriaAustralia
| | - Denny Meyer
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
| | - Thushara Perera
- Bionics InstituteEast MelbourneVictoriaAustralia
- Department of Medical BionicsThe University of MelbourneMelbourneVictoriaAustralia
| | - Peter Bosanac
- St Vincent's HospitalMelbourneVictoriaAustralia
- Department of PsychiatryUniversity of MelbourneMelbourneVictoriaAustralia
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Gadot R, Najera R, Hirani S, Anand A, Storch E, Goodman WK, Shofty B, Sheth SA. Efficacy of deep brain stimulation for treatment-resistant obsessive-compulsive disorder: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328738. [PMID: 36127157 DOI: 10.1136/jnnp-2021-328738] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/22/2022] [Indexed: 11/03/2022]
Abstract
Deep brain stimulation (DBS) is an established and growing intervention for treatment-resistant obsessive-compulsive disorder (TROCD). We assessed current evidence on the efficacy of DBS in alleviating OCD and comorbid depressive symptoms including newly available evidence from recent trials and a deeper risk of bias analysis than previously available. PubMed and EMBASE databases were systematically queried using Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We included studies reporting primary data on multiple patients who received DBS therapy with outcomes reported through the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Primary effect measures included Y-BOCS mean difference and per cent reduction as well as responder rate (≥35% Y-BOCS reduction) at last follow-up. Secondary effect measures included standardised depression scale reduction. Risk of bias assessments were performed on randomised controlled (RCTs) and non-randomised trials. Thirty-four studies from 2005 to 2021, 9 RCTs (n=97) and 25 non-RCTs (n=255), were included in systematic review and meta-analysis based on available outcome data. A random-effects model indicated a meta-analytical average 14.3 point or 47% reduction (p<0.01) in Y-BOCS scores without significant difference between RCTs and non-RCTs. At last follow-up, 66% of patients were full responders to DBS therapy. Sensitivity analyses indicated a low likelihood of small study effect bias in reported outcomes. Secondary analysis revealed a 1 standardised effect size (Hedges' g) reduction in depressive scale symptoms. Both RCTs and non-RCTs were determined to have a predominantly low risk of bias. A strong evidence base supports DBS for TROCD in relieving both OCD and comorbid depression symptoms in appropriately selected patients.
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Affiliation(s)
- Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ricardo Najera
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Samad Hirani
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adrish Anand
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Eric Storch
- Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Wayne K Goodman
- Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Ben Shofty
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Mar-Barrutia L, Real E, Segalás C, Bertolín S, Menchón JM, Alonso P. Deep brain stimulation for obsessive-compulsive disorder: A systematic review of worldwide experience after 20 years. World J Psychiatry 2021; 11:659-680. [PMID: 34631467 PMCID: PMC8474989 DOI: 10.5498/wjp.v11.i9.659] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/02/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Twenty years after its first use in a patient with obsessive-compulsive disorder (OCD), the results confirm that deep brain stimulation (DBS) is a promising therapy for patients with severe and resistant forms of the disorder. Nevertheless, many unknowns remain, including the optimal anatomical targets, the best stimulation parameters, the long-term (LT) effects of the therapy, and the clinical or biological factors associated with response. This systematic review of the articles published to date on DBS for OCD assesses the short and LT efficacy of the therapy and seeks to identify predictors of response.
AIM To summarize the existing knowledge on the efficacy and tolerability of DBS in treatment-resistant OCD.
METHODS A comprehensive search was conducted in the PubMed, Cochrane, Scopus, and ClinicalTrials.gov databases from inception to December 31, 2020, using the following strategy: “(Obsessive-compulsive disorder OR OCD) AND (deep brain stimulation OR DBS).” Clinical trials and observational studies published in English and evaluating the effectiveness of DBS for OCD in humans were included and screened for relevant information using a standardized collection tool. The inclusion criteria were as follows: a main diagnosis of OCD, DBS conducted for therapeutic purposes and variation in symptoms of OCD measured by the Yale-Brown Obsessive-Compulsive scale (Y-BOCS) as primary outcome. Data were analyzed with descriptive statistics.
RESULTS Forty articles identified by the search strategy met the eligibility criteria. Applying a follow-up threshold of 36 mo, 29 studies (with 230 patients) provided information on short-term (ST) response to DBS in, while 11 (with 155 patients) reported results on LT response. Mean follow-up period was 18.5 ± 8.0 mo for the ST studies and 63.7 ± 20.7 mo for the LT studies. Overall, the percentage of reduction in Y-BOCS scores was similar in ST (47.4%) and LT responses (47.2%) to DBS, but more patients in the LT reports met the criteria for response (defined as a reduction in Y-BOCS scores > 35%: ST, 60.6% vs LT, 70.7%). According to the results, the response in the first year predicts the extent to which an OCD patient will benefit from DBS, since the maximum symptom reduction was achieved in most responders in the first 12-14 mo after implantation. Reports indicate a consistent tendency for this early improvement to be maintained to the mid-term for most patients; but it is still controversial whether this improvement persists, increases or decreases in the long term. Three different patterns of LT response emerged from the analysis: 49.5% of patients had good and sustained response to DBS, 26.6% were non responders, and 22.5% were partial responders, who might improve at some point but experience relapses during follow-up. A significant improvement in depressive symptoms and global functionality was observed in most studies, usually (although not always) in parallel with an improvement in obsessive symptoms. Most adverse effects of DBS were mild and transient and improved after adjusting stimulation parameters; however, some severe adverse events including intracranial hemorrhages and infections were also described. Hypomania was the most frequently reported psychiatric side effect. The relationship between DBS and suicide risk is still controversial and requires further study. Finally, to date, no clear clinical or biological predictors of response can be established, probably because of the differences between studies in terms of the neuroanatomical targets and stimulation protocols assessed.
CONCLUSION The present review confirms that DBS is a promising therapy for patients with severe resistant OCD, providing both ST and LT evidence of efficacy.
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Affiliation(s)
- Lorea Mar-Barrutia
- OCD Clinical and Research Unit, Department of Psychiatry, Hospital de Bellvitge, Barcelona 08907, Spain
| | - Eva Real
- OCD Clinical and Research Unit, Department of Psychiatry, Hospital de Bellvitge, Barcelona 08907, Spain
- Bellvitge Biomedical Research Institute-IDIBELL, Barcelona 08907, Spain
- CIBERSAM (Centro de Investigación en Red de Salud Mental), Carlos III Health Institute, Madrid 28029, Spain
| | - Cinto Segalás
- OCD Clinical and Research Unit, Department of Psychiatry, Hospital de Bellvitge, Barcelona 08907, Spain
- Bellvitge Biomedical Research Institute-IDIBELL, Barcelona 08907, Spain
- CIBERSAM (Centro de Investigación en Red de Salud Mental), Carlos III Health Institute, Madrid 28029, Spain
| | - Sara Bertolín
- OCD Clinical and Research Unit, Department of Psychiatry, Hospital de Bellvitge, Barcelona 08907, Spain
| | - José Manuel Menchón
- OCD Clinical and Research Unit, Department of Psychiatry, Hospital de Bellvitge, Barcelona 08907, Spain
- Bellvitge Biomedical Research Institute-IDIBELL, Barcelona 08907, Spain
- CIBERSAM (Centro de Investigación en Red de Salud Mental), Carlos III Health Institute, Madrid 28029, Spain
- Department of Clinical Sciences, Faculty of Medicine, University of Barcelona, Barcelona 08907, Spain
| | - Pino Alonso
- OCD Clinical and Research Unit, Department of Psychiatry, Hospital de Bellvitge, Barcelona 08907, Spain
- Bellvitge Biomedical Research Institute-IDIBELL, Barcelona 08907, Spain
- CIBERSAM (Centro de Investigación en Red de Salud Mental), Carlos III Health Institute, Madrid 28029, Spain
- Department of Clinical Sciences, Faculty of Medicine, University of Barcelona, Barcelona 08907, Spain
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Acevedo N, Bosanac P, Pikoos T, Rossell S, Castle D. Therapeutic Neurostimulation in Obsessive-Compulsive and Related Disorders: A Systematic Review. Brain Sci 2021; 11:brainsci11070948. [PMID: 34356182 PMCID: PMC8307974 DOI: 10.3390/brainsci11070948] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 01/16/2023] Open
Abstract
Invasive and noninvasive neurostimulation therapies for obsessive-compulsive and related disorders (OCRD) were systematically reviewed with the aim of assessing clinical characteristics, methodologies, neuroanatomical substrates, and varied stimulation parameters. Previous reviews have focused on a narrow scope, statistical rather than clinical significance, grouped together heterogenous protocols, and proposed inconclusive outcomes and directions. Herein, a comprehensive and transdiagnostic evaluation of all clinically relevant determinants is presented with translational clinical recommendations and novel response rates. Electroconvulsive therapy (ECT) studies were limited in number and quality but demonstrated greater efficacy than previously identified. Targeting the pre-SMA/SMA is recommended for transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). TMS yielded superior outcomes, although polarity findings were conflicting, and refinement of frontal/cognitive control protocols may optimize outcomes. For both techniques, standardization of polarity, more treatment sessions (>20), and targeting multiple structures are encouraged. A deep brain stimulation (DBS) 'sweet spot' of the striatum for OCD was proposed, and CBT is strongly encouraged. Tourette's patients showed less variance and reliance on treatment optimization. Several DBS targets achieved consistent, rapid, and sustained clinical response. Analysis of fiber connectivity, as opposed to precise neural regions, should be implemented for target selection. Standardization of protocols is necessary to achieve translational outcomes.
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Affiliation(s)
- Nicola Acevedo
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
- Correspondence:
| | - Peter Bosanac
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
- Department of Psychiatry, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Toni Pikoos
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
| | - Susan Rossell
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
| | - David Castle
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
- Department of Psychiatry, University of Melbourne, Melbourne, VIC 3010, Australia
- Centre for Addiction and Mental Health, 252 College Street, Toronto, ON M5T 1R7, Canada
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Li YH, Zhao K, Wang MQ, Wang J, Gao BL. Stereotactic radiofrequency thermocoagulation application in the anterior limbs of patients' internal capsules in treating intractable tic disorders. Int J Hyperthermia 2020; 37:332-337. [PMID: 32253951 DOI: 10.1080/02656736.2020.1748237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Purpose: To investigate the effect of applying stereotactic radiofrequency thermocoagulation in the anterior limbs of patients' internal capsules in treating intractable tic disorders.Materials and methods: Patients diagnosed with intractable tic disorders were prospectively enrolled and treated using stereotactic radiofrequency thermocoagulation in the anterior limbs of the internal capsules. Periprocedural complications, effects, and follow-up outcomes were then analyzed.Results: Fifty patients were enrolled, including 38 with Tourette syndrome and 12 with persistent refractory vocal or motor tic disorders. The radiofrequency thermocoagulation procedure was performed successfully in all patients. Five participants (10%) experienced periprocedural complications, including one having a slight hemiplegia, two developing fevers (4%), and two developing urination disorders (4%). The participants underwent a follow-up for 12 months, with excellent effects being achieved in 23 patients (46%), prominent results in 13 (26%), good results in 10 (20%), and invalid results in 4 (8%), reaching an efficacy rate of 92% (46/50). Thirty-six patients experienced excellent and prominent effects, with no additional management after the radiofrequency ablation being needed, achieving a success rate of 72%. After radiofrequency thermocoagulation, the Yale Global Tic Severity Scale (YGTSS) scores were significantly reduced (p < .01) when compared with those before the procedure. Following this procedure, participants' serum dopamine levels (SDA) significantly decreased (p < .05), while their serotonin levels were significantly elevated (p < .05) when compared to the measurements taken before the procedure.Conclusion: Stereotactic radiofrequency thermocoagulation applied to the anterior limbs of patients' internal capsules may be effective for treating intractable tic disorders, without risk of serious complications.
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Affiliation(s)
- Yu-Hui Li
- Department of Neurosurgery, Shijiazhuang First Hospital, Hebei Medical University, Shijiazhuang, China
| | - Kai Zhao
- Department of Neurosurgery, Shijiazhuang First Hospital, Hebei Medical University, Shijiazhuang, China
| | - Mei-Qing Wang
- Department of Neurosurgery, Shijiazhuang First Hospital, Hebei Medical University, Shijiazhuang, China
| | - Jing Wang
- Department of Neurology, Shijiazhuang First Hospital, Hebei Medical University, Shijiazhuang, China
| | - Bu-Lang Gao
- Department of Medical Research, Shijiazhuang First Hospital, Hebei Medical University, Shijiazhuang, China
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